Esofagitis necrotizante aguda / Acute necrotizing esophagitis / Esofagite necrotizante aguda

La esofagitis necrotizante aguda es un trastorno poco común que puede ser causa de hemorragia digestiva alta. Predomina en el sexo masculino en la sexta década de la vida. El diagnóstico es endoscópico y muestra una mucosa esofágica de apariencia negra que afecta al esófago distal en toda su circunferencia y se detiene abruptamente en la unión gastroesofágica. Clínicamente suele presentarse con hematemesis y melenas, shock hipovolémico por sangrado masivo, siendo otras manifestaciones el dolor epigástrico, molestia retroesternal y disfagia. Se vincula a pacientes con antecedentes de enfermedad cardiovascular, alcoholismo, diabetes mellitus, desnutrición, hernia hiatal, estenosis gastroduodenal, cáncer, así como pacientes en shock, traumatizados, sometidos a cirugía mayor e inmunosuprimidos. El tratamiento se basa en fluidoterapia, inhibidores de la bomba de protones y suspensión de la vía oral, siendo controvertido el uso de antibioticoterapia. Su pronóstico es malo y dependerá de la gravedad de la enfermedad esofágica y del terreno del paciente, con una mortalidad de hasta el 36 %. Presentamos el caso clínico de un paciente de 81 años, hipertenso, que presenta hematemesis, confirmándose en la endoscopía una esofagitis necrotizante aguda, que evoluciona favorablemente con tratamiento médico.

Acute necrotizing esophagitis is a rare disorder that can cause upper gastrointestinal bleeding. It predominates in males in the sixth decade of life. The diagnosis is endoscopic and shows a black-appearing esophageal mucosa that affects the entire circumference of the distal esophagus and stops abruptly at the gastroesophageal junction. Usually, patients present with hematemesis and melena, with other manifestations such as epigastric pain, retrosternal discomfort, dysphagia, and hypovolemic shock. Almost all patients reported comorbidities: cardiovascular disease, alcoholism, diabetes mellitus, malnutrition, hiatal hernia, gastroduodenal stenosis, and malignant neoplasia; is related as well to patients with shock, trauma, undergoing major surgery, and immunosuppression. The treatment is based on fluid reposition, proton pump inhibitors and suspension of the oral route, the use of antibiotic therapy being controversial. Its prognosis is poor and will depend on the severity of the esophageal disease and the patient comorbidities, with a mortality rate up to 36 %. Case: A 81-year-old male patient with hypertension, who presented hematemesis, confirmed by endoscopy as acute necrotizing esophagitis, whose evolution was favorable with medical treatment.

A esofagite necrosante aguda é uma doença rara que pode causar hemorragia digestiva alta. Predomina no sexo masculino na sexta década de vida. O diagnóstico é endoscópico e mostra uma mucosa esofágica circunferencial difusa com aspecto preto que envolve quase universalmente o esôfago distal e para abruptamente na junção gastroesofágica. Clinicamente, geralmente se apresenta com hematêmese e melena, com outras manifestações sendo dor epigástrica, desconforto retroesternal, disfagia e choque hipovolêmico. Está relacionado a pacientes com histórico de doenças cardiovasculares, alcoolismo, diabetes mellitus, desnutrição, hérnia hiatal, estenose gastroduodenal e neoplasia maligna, bem como pacientes em choque, trauma, cirurgia de grande porte e imunossupressão. O tratamento é a medicação dietética higiênica baseada em fluidoterapia, inibidores da bomba de prótons e suspensão da via oral, sendo o uso de antibioticoterapia controverso. Seu prognóstico é ruim e dependerá da gravidade da doença esofágica e do terreno do paciente, com mortalidade de até 36 %. Apresentamos o caso clínico de um paciente hipertenso de 81 anos que apresentou hematêmese, confirmada por endoscopia como esofagite necrosante aguda, que evoluiu favoravelmente com tratamento higiênico-dietético e medicamentoso.

Usefulness of Contrast-Enhanced CT in a Patient with Acute Phlegmonous Esophagitis: A Case Report and Literature Review.

Acute phlegmonous esophagitis is a very rare, life-threatening form of esophagitis, characterized by diffuse bacterial infection and pus formation within the submucosal and muscularis layers of the esophagus. We describe a case in which contrast-enhanced chest CT was useful for evaluating the severity of phlegmonous esophagitis, which was overlooked and underestimated by endoscopy.

Erosive esophagitis secondary to radiotherapy: Case report / Esofagitis erosiva secundaria a radioterapia: reporte de un caso

Abstract Introduction: Erosive esophagitis secondary to radiotherapy is an unusual complication in the oncological treatment of thoracic tumors. This pathological entity is associated with multiple complications, which is a clinical challenge for health workers unfamiliar with the clinical manifestations. Clinical case: A 64-year-old woman with a 3-day clinical picture of chest pain radiating to the epigastrium with 10/10 intensity. On physical examination, she was tachycardic, hypotensive, and with intense pain in the upper hemiabdomen region; she had no signs of peritoneal irritation on deep palpation. Paraclinical tests showed no signs of local or disseminated infection, but endoscopy of the digestive tract reported post-radiation esophagitis. Discussion: Erosive esophagitis after radiotherapy occurs in less than 1 % of cases, and clinical manifestations such as dysphagia, odynophagia, and abdominal pain are common. Initial symptomatic management is preserved, with supportive measures such as intravenous hydration and proton pump inhibitors (PPIs). In case of intolerance to the oral route, therapy with nutritional support is indicated via nasogastric tube or gastrostomy in the most severe cases.

Resumen Introducción: la esofagitis erosiva secundaria a la radioterapia es una complicación inusual del tratamiento oncológico de los tumores torácicos. Esta entidad patológica está asociada con múltiples complicaciones, lo que resulta un reto clínico para los profesionales en salud que están poco familiarizados con las manifestaciones clínicas. Caso clínico: mujer de 64 años con cuadro clínico de 3 días de dolor torácico irradiado al epigastrio con intensidad 10/10. En el examen físico se encontró taquicárdica, hipotensa, con dolor intenso en la región hemiabdominal superior; a la palpación profunda no tenía signos de irritación peritoneal. Los paraclínicos no mostraron signos de infección local o diseminada, pero la endoscopia de vías digestivas reportó esofagitis posirradiación. Discusión: la esofagitis erosiva posterior a la radioterapia se presenta en menos del 1 % de los casos, las manifestaciones clínicas como disfagia, odinofagia y dolor abdominal son frecuentes; el manejo sintomático inicial es conservado, con medidas de soporte como hidratación intravenosa e inhibidores de la bomba de protones (IBP). En caso de intolerancia a la vía oral se indica terapia con soporte nutricional por sonda nasogástrica o gastrostomía en los casos más graves.

Lymphocytic Esophagitis Is Not Similar to Eosinophilic Esophagitis Except for Seasonal Variation.

OBJECTIVE: Unlike eosinophilic esophagitis (EoE), there is no consensus on the minimum number of intraepithelial lymphocytes (IEL) that is diagnostic of lymphocytic esophagitis (LyE). The aim of this study was to determine whether significant correlations exist between the numbers of intraepithelial lymphocytes (IEL) in esophageal biopsies and clinical and endoscopic manifestations usually associated with EoE. METHODS: H&E slides from esophageal biopsies from 330 patients were reviewed. The number of IEL and intraepithelial eosinophils (IEE) per mm2 was counted in the area with the highest concentration in each biopsy. The numbers were then correlated with clinical and endoscopic findings. RESULTS: As expected, a higher number of IEE was significantly associated with food impaction (p=0.001), dysphagia (p=0.021), esophageal stricture (p=0.017), rings (P<0.0001), and furrows (p<0.0001). By contrast, there was no significant association between increased IEL and any of the aforementioned clinical and endoscopic features in the original 330 patients or in a subset of 233 patients with no IEE. Interestingly, the number of both IEE and IEL varied significantly by the season when the biopsy was obtained, being lowest in the fall and highest in the spring (p=0002 for IEE and p<0.0001 for IEL). CONCLUSION: In esophageal biopsies, increased IEL has no significant correlation with food impaction or dysphagia or with esophageal stricture, rings, or furrows. There is significant variation in the number of IEL depending on the season when the biopsy is obtained, which has not been previously reported.

Caracterización de pacientes con lesiones premalignas de esófago / Characterization of patients with esophagus premalignant lesions

Introducción: Los tumores de esófago constituyen lesiones benignas o malignas, que afectan las diferentes capas del órgano. Objetivo: Caracterizar a pacientes con lesiones premalignas de esófago halladas en endoscopia bucal, según variables seleccionadas. Métodos: Se efectuó un estudio observacional, descriptivo y transversal en el Servicio de Gastroenterología del Hospital General Docente Dr. Juan Bruno Zayas Alfonso de Santiago de Cuba, durante el 2015. El universo estuvo constituido por 57 pacientes de 20 años y más, con diagnóstico endoscópico e histológico de lesión premaligna de esófago. Las variables analizadas fueron: edad, sexo, lesiones premalignas de esófago, grado de esofagitis y diagnóstico histológico. Resultados: La endoscopia mostró un predominio de la esofagitis por reflujo en los pacientes de 62 años y más (61,7 %), así como del grado A de la clasificación de los Ángeles en ambos sexos (39,7 y 30,1 % de mujeres y hombres, respectivamente). Según el diagnóstico histológico primaron la esofagitis crónica (48,4 %) y la esofagitis crónica con displasia (17,1 %). Conclusiones: La identificación de pacientes con lesiones premalignas de esófago constituye el punto de partida para futuras acciones preventivas e intervencionistas, con vistas a disminuir la incidencia del cáncer de esófago.

Introduction: The esophagus malignancies constitute benign or malignant lesions that affect the different layers of the organ. Objective: To characterize patients with esophagus premalignant lesions found in oral endoscopy, according to selected variables. Methods: An observational, descriptive and cross-sectional study was carried out in the Gastroenterology Service of Dr. Juan Bruno Zayas Alfonso Teaching General Hospital in Santiago de Cuba, during 2015. The universe was constituted by 57 patients aged 20 and over, with endoscopic and histologic diagnosis of esophagus premalignant lesion. The analyzed variables were: age, sex, esophagus premalignant lesions, degree of esophagitis and histologic diagnosis. Results: The endoscopy showed a prevalence of the esophagitis by reflux in patients aged 62 and over (61.7 %), as well as of the grade A of Los Angeles classification in both sexes (39.7 and 30.1% of women and men, respectively). According to the histologic diagnosis there was a prevalence of chronic esophagitis (48.4 %) and chronic esophagitis with dysplasia (17.1 %). Conclusions: The identification of patients with esophagus premalignant lesions constitutes the starting point for future preventive and interventionists actions, aimed at diminishing the incidence of esophagus cancer.

Esofagitis flemonosa aguda, a propósito de un caso / No disponible

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Acute phlegmonous esophagitis: apropos of a case.

A 43-year-old male with an uneventful history presented with fever and ingestion-triggered retrosternal chest pain of a three-day duration, which was aggravated by deep breathing and the supine position. When asked regarding the possible ingestion of a foreign body he recalled having accidentally swallowed tiny glass shards from a broken bottle.

The yield, effectiveness and safety of gastroscopy in management of early postbariatric upper gastrointestinal pain.

BACKGROUND: Upper gastrointestinal (GI) symptoms are prevalent among patients after -bariatric surgeries. Gastroscopy is an important procedure to investigate symptoms. Our primary aim was to evaluate the yield, effectiveness and safety of gastroscopy procedure obtained in a 3-months period after bariatric operation for exploring upper GI symptoms origin. METHODS: Single center, retrospective study at the EMMS Nazareth Hospital from 2010 to 2018. All patients who underwent gastric-bypass (either Roux-en-Y[R-en-Y] or Mini-gastric bypass [MGB]) and who experienced early upper GI symptoms were included in the study. RESULTS: A total of 428 were included in the study. Among them, 154 patients (36%) underwent R-en-Y surgery and 274 (64%) underwent MGB. Baseline characteristics were similar in the two groups. The mean age in the R-en-Y group was 42.3±10.8 vs. 42.8±11.2 in the MGB group. Thirty-nine patients underwent gastroscopy, more in the R-en-Y group compared to MGB group (11.6% vs. 7.6%, P<0.005). In the MGB group, more patients had normal surgical anatomy (23.1%) vs. 12.8% in the R-en-Y group, and the prevalence of erosive esophagitis was 14.2% in the MBG group vs. 5.5% in the R-en-Y group, P<0.005. On the other hand, marginal ulcer was more frequent after R-en-Y than MGB surgery (16.6% vs. 9.5%, P<0.005). No procedural related complication was observed in both groups. CONCLUSIONS: Upper GI symptoms in the early postbariatric surgery period are common with most endoscopic examination revealing normal postsurgical anatomy. In this setting, gastroscopy is safe, without procedural related complications.

Role of Multimodality Imaging in Gastroesophageal Reflux Disease and Its Complications, with Clinical and Pathologic Correlation.

Gastroesophageal reflux disease (GERD) is a common condition and impairs the quality of life for millions of patients, accounts for considerable health care spending, and is a primary risk factor for esophageal adenocarcinoma. There have been substantial advances in understanding the pathogenesis of GERD and its complications and much progress in diagnosis and management of GERD; however, these have not been comprehensively discussed in the recent radiology literature. Understanding the role of imaging in GERD and its complications is important to aid in multidisciplinary treatment of GERD. GERD results from prolonged or recurrent reflux of gastric contents into the esophagus. Common symptoms include heartburn or regurgitation. Prolonged reflux of gastric contents into the esophagus can cause erosive esophagitis. Over time, the inflammatory response related to esophagitis can lead to deposition of fibrous tissue and development of strictures. Alternatively, the esophageal mucosa can undergo metaplasia (Barrett esophagus), a precursor to dysplasia (which can lead to adenocarcinoma). Conventional barium esophagography has long been considered the primary imaging modality for the esophagus, and the fluoroscopic findings for diagnosis of GERD have been well established. Multimodality imaging has a clear role in detection and assessment of the complications of GERD, specifically reflux esophagitis and Barrett esophagus; differentiation of benign and malignant strictures; and detection, staging, and posttreatment surveillance of esophageal adenocarcinoma. Given the dramatic changes in utilization of abdominal imaging during the past 2 decades, with significantly declining volume of fluoroscopic procedures and concomitant increase in CT and MRI studies, it is crucial that modern radiologists appreciate the value of barium esophagography in the workup of GERD and recognize the key imaging features of GERD and its complications at CT and MRI.

A Creeping Malaise Leading to Calamity: Herpes Esophagitis Perforation.

Herpes simplex virus is an uncommon cause of esophagitis and particularly so in immunocompetent individuals. Although the common presentation tends to be odynophagia and/or dysphagia, fever, and retrosternal chest pain, there are variations and rarely it can present more ominously as esophageal rupture. We report a rare case of esophageal perforation with penetration into the vertebral space secondary to chronic herpes simplex virus esophagitis in a 71-year-old immunocompetent woman. This is the second known such occurrence. The patient had a long stay in the hospital but recovered from the condition and was followed up for 1 year after initial presentation.

Pill-induced esophagitis caused by ingesting excessive caffeine tablets.

A 19-year-old woman with suicidal thoughts consumed 24 anhydrous caffeine tablets and was admitted to our hospital. After being discharged from the hospital, her oral intake remained impaired because of retrosternal pain and she was readmitted. An upper gastrointestinal endoscopy revealed diffuse ulcers throughout the mid-to-lower esophagus; the patient was diagnosed with caffeine-induced esophagitis. She recovered soon after conservative treatment. A follow-up endoscopy performed 1 month after the patient was discharged showed that the ulcers had healed. This case highlights the risk of esophageal injuries after ingesting excessive caffeine tablets, which were sold as dietary supplement without a prescription. Our experience indicates that endoscopic surveillance is advisable to prevent severe complications if a patient presents with esophageal symptoms suggestive of chemical esophagitis.

Esofagitis enfisematosa con perforación gástrica / Emphysematous esophagitis with gastric perforation

La esofagitis enfisematosa es una entidad extremadamente infrecuente sin prácticamente ningún caso descrito en la literatura. Presentamos el caso de una paciente con esofagitis y gastritis enfisematosa con afectación de toda la pared del esófago y el estómago al diagnóstico. Fue intervenida quirúrgicamente por perforación gástrica en dos ocasiones, realizándose cierre primario en ambas con evolución posterior favorable. Pese a la gran extensión de la esófago-gastritis enfisematosa al diagnóstico y la presencia de una perforación gástrica, es seguro realizar un manejo semejante a la gastritis enfisematosa siendo lo más conservadores posibles en caso de precisar cirugía

Emphysematous esophagitis is an extremely rare disease and there are very few previous reports in the literature. We report a case of emphysematous esophagitis and gastritis with complete affectation of the gastric and esophageal wall at diagnosis. Two surgical interventions were performed due to gastric perforation that was treated in both cases with primary closure. The post-operative recovery was satisfactory. Despite the large emphysematous esophago-gastritis affectation at diagnosis and the presence of gastric perforation, it is safe to perform the same management principles as with emphysematous gastritis. This should be as conservative as possible in case a surgical procedure is required